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Chapter 7 Neighborhood Clinics: An Academic Medical Center–Community Health Center Partnership Mina Silberberg Kimberly S. H. Yarnall Fred Johnson Devdutta Sangvai Rupal Patel Susan D. Yaggy The number of uninsured and underinsured in the United States is growing, and the challenges of their care are complex. The providers and services available to the un/underinsured are limited, and financial barriers are compounded by such obstacles as lack of transportation and language nonconcordance between providers and patients.– The result for consumers is insufficient, delayed, or fragmented care, with adverse health consequences. The result for the health care system is emergency department (ED) use for primary and non-emergent acute care needs, as well as unnecessary hospitalizations and ED visits for ambulatory-care-sensitive conditions. What can academic medical centers (AMCs) do to help? This chapter describes the Lyon Park Clinic, a neighborhood clinic created and run through the partnership of a federally qualified health center (FQHC) and an AMC. Since this writing began, a second such clinic has been opened through the same partnership and is operating successfully; discussions have begun about a third clinic. Because Lyon Park Clinic has had time to develop, this chapter will focus on its history, operation , finances, services, and patient base. Community health centers are essential to the health care safety net but are stretched thin. In the 1990s the number of individuals served by these centers Mina Silberberg, PhD, is an assistant professor of community and family medicine at the Duke University Medical Center (DUMC) and Duke Translational Medicine Institute (DTMI). Kimberly S. H. Yarnall, MD, is an associate professor and the medical director of the Division of Community Health at DUMC. Fred Johnson, MBA, is an assistant professor and a deputy director of the Division of Community Health, DUMC. Devdutta Sangvai, MD, MBA, is the division chief of family medicine, medical director of the Duke Center for Eating Disorders, and vice chair of quality and safety, community and family medicine, DUMC. Rupal Patel, MPP, is a former research analyst at DUMC now living in the United Kingdom. Susan D. Yaggy, MPA, is chief of the Division of Community Health, DUMC, and associate director of the Duke Center for Community Research of the DTMI. Neighborhood Clinics 71 grew, as did the proportion who were uninsured; a 2000 report concluded that 50% of FQHCs faced operational or financial problems. While the funding for community health centers has increased in recent years, overall federal spending on the safety net has not kept pace with the rise in the number of uninsured. Hill and Madara argue that urban AMCs should complement, rather than substitute for, community-based clinicians in general, and community health centers in particular. As a provider of highly specialized care, an AMC serves a larger community than the one in which it is located. Conversely, when an AMC takes on a large role in providing primary care, it can hurt community providers’ bottom line. “The responsibility of the urban academic medical center,” the authors conclude, “is to assist in protecting the primary care capacity of urban neighborhoods , not to compete with them” (p. 2220). The authors of this report add that the responsibilities of the AMC include developing new models of care—not only new surgical approaches and pharmaceuticals , but also new financial and organizational approaches to meeting health care needs. There have been collaborations between FQHCs and AMCs for years, but they principally provide training opportunities for AMC learners in the FQHC. Health systems have also provided funds and resources to FQHCs in return for the latter shouldering a disproportionate share of indigent care. The partnership described here, between Duke University Medical Center and Lincoln Community Health Center, an FQHC, represents a different approach, one which we believe meets the mandates to enhance community-based primary care and develop new approaches to meeting community needs. Theservicemodelisfamiliarfromruralclinics,smallFQHCs,andnurse-managed health centers; mid-level practitioners under off-site physician supervision provide primary, preventive, and acute services, as well as referrals and limited labwork on site. However, the administrative and financial partnership that makes the model possible is new. For example, nurse-managed health centers are often ineligible for cost-based reimbursement from Medicaid and Medicare, threatening their financial viability. The neighborhood clinic described here would be ineligible as well, except for the FQHC’s role in running it. As will be described, this is one of several benefits deriving from the FQHC-AMC partnership that the clinic represents. Clinic Model Durham, North Carolina...

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